title: Referral pathways of patients with gallstones: a potential source of financial waste in the U.K. National Health Service?
abstract: OBJECTIVE
  Gallstone-related illnesses are one of the most common reasons for emergency hospital admissions, often with serious complications. Standard treatment of uncomplicated gallstone-disease is by laparoscopic cholecystectomy, which can be safely and cost-effectively performed during a short hospital stay or as day-case. This paper aims to evaluate the referral pattern of patients with gallstones, which treatment is given and whether patients admitted as emergency could have benefited from earlier elective referral. The management of these patients is examined in the context of payment by results to determine cost and potential savings.
  
  
  METHODS
  The approach takens was prospective clinical audit and patient questionnaire in a district general hospital. Cost comparisons were made using secondary care income (NHS tariff) and estimated cost of hospitalisation, investigations and treatment.
  
  
  RESULTS
  Between May and July 2007, 114 patients were admitted with symptomatic gallstones, 62 (54.4 per cent) were emergencies. Cholecystectomy was performed in all 52 elective patients and performed or planned for 59/62 (95.2 per cent) emergencies. A total 17/62 emergencies (27.4 per cent) presented with complications of gallstones. 38/62 (61.3 per cent) had similar symptoms before, with 21/38 (55.3 per cent) diagnosed in primary care or by another hospital department. 11 (52.4 per cent) of these had not been referred for a surgical opinion; taking account of age, co-morbidity and data acquired for elective admissions, the cost of their treatment could have been reduced by at least pounds 16,194.
  
  
  CONCLUSIONS
  A large proportion of patients admitted with symptomatic biliary disease could have been referred earlier and electively. Such referral practice could improve the quality of care and reduce cost for the NHS both in primary and secondary care.
authors.affiliation: Northumbria Healthcare NHS Foundation Trust, North Shields, UK. DWBorowski@AOL.com
authors.forename: David
authors.initials: D
authors.lastname: Borowski
authors.forename: Margaret
authors.initials: M
authors.lastname: Knox
authors.forename: Venkat
authors.initials: V
authors.lastname: Kanakala
authors.forename: Stuart
authors.initials: S
authors.lastname: Richardson
authors.forename: Keith
authors.initials: K
authors.lastname: Seymour
authors.forename: Stephen
authors.initials: S
authors.lastname: Attwood
authors.forename: Bary
authors.initials: B
authors.lastname: Slater
mesh_terms: D000368:Aged; D002763:Cholecystectomy / Q000191:economics* / Q000706:statistics & numerical data; D054869:Clinical Audit; D003365:Costs and Cost Analysis; D004636:Emergency Service, Hospital / Q000191:economics*; D005260:Female; D042882:Gallstones / Q000191:economics* / Q000601:surgery; D006801:Humans; D008297:Male; D008875:Middle Aged; D009313:National Health Programs / Q000191:economics*; D011446:Prospective Studies; D012017:Referral and Consultation / Q000191:economics* / Q000592:standards; D011795:Surveys and Questionnaires; D006113:United Kingdom